Medical management of the patient with an ectopic pregnancy.

Ectopic pregnancies are the leading cause of pregnancy-related death during the first trimester. Historically, the treatment for an ectopic pregnancy was emergency laparotomy, which included salpingectomy. In 1987, research began at the Regional Medical Center at Memphis, in conjunction with the University of Tennessee, examining early detection and medical treatment for ectopic pregnancy. Pharmacologic management of an unruptured, size-appropriate ectopic pregnancy is now an established standard of care. The present protocol recommends single-dose methotrexate. This form of methotrexate has proven to be a successful, cost-effective alternative to traditional surgical management of ectopic pregnancies.

A comparison of the cost of local versus general anesthesia for laparoscopic sterilization in an operating room setting.

OBJECTIVE: To compare the charges between laparoscopic sterilization performed under either local or general anesthesia in a traditional operating room setting with anesthesia personnel in attendance. DESIGN: A retrospective review of charges. SETTING: The Regional Medical Center, Memphis, Tennessee. PATIENTS: Sixty-five women undergoing laparoscopic sterilization, 33 under local and 32 under general anesthesia. Interventions. Laparoscopic sterilization. MEASUREMENTS AND MAIN RESULTS: Patient demographics, history of pelvic inflammatory disease, and history of previous surgery were similar for both groups. Operating room and recovery room times were shorter for patients whose procedures were performed under local anesthesia. Flat-rate fee schedules reduced the cost savings for cases performed under local anesthesia to $529 dollars per case, with 76% ($402) of the savings related to anesthetic drugs or equipment. CONCLUSION: Although these savings appear minimal on a per case basis, if 50% of the approximately 210,000 laparoscopic sterilizations performed in the United States each year were performed under local anesthesia, a savings of over $55 million could be achieved (105,000 cases X $529 = $55,545,000). This would result in substantial overall monetary savings to the health care system.

Outpatient vaginal hysterectomy as a new trend in gynecology.

A large number of vaginal hysterectomies are performed on an outpatient basis through ambulatory surgery units (ASU). Recognizing this trend, we researched the possibility of performing vaginal hysterectomies in our ASU and developed an outpatient vaginal hysterectomy protocol. The preoperative and postoperative education we provide to patients is the key to our protocol's success. After conducting patient satisfaction surveys, we reached the conclusion that outpatient vaginal hysterectomies are a successful alternative to inpatient vaginal hysterectomies for many of our patients.

Laparoscopic equipment troubleshooting.

1. A successful laparoscopy program requires dedicated personnel, standardized inventory, and ongoing inservice training. Members of the operating team must realize their individual responsibilities and establish accountability while providing safe, efficient care for their patients. 2. A standardized inventory and checklist of all laparoscopic equipment and instrumentation deemed necessary for the procedure by the physician must be maintained and checked on a daily basis. 3. Adequate primary and backup instrumentation must be readily available at all times.

The effect of same-day pregnancy testing on the incidence of luteal phase pregnancy.

OBJECTIVE: To assess the impact of same-day pregnancy testing on the incidence of luteal phase pregnancy (pregnancy in which conception occurs before sterilization). METHODS: Retrospectively, all patients (N = 1006) undergoing laparoscopic tubal ligations at the Regional Medical Center, Memphis, from May 1990 through December 1991 were reviewed for sterilization failures. Negative urine pregnancy tests were documented on all scheduled patients at their preoperative examination. After the first 401 sterilizations, same-day pregnancy testing with enzyme-linked immunosorbent assay (ELISA) pregnancy tests was instituted. We reviewed the records of all presumed sterilization failures as well as all patients with a positive pregnancy test on the day of surgery. Last menstrual period, ultrasound records, and date of delivery were analyzed to determine time of conception. RESULTS: Seven luteal phase pregnancies were discovered among the first 401 sterilization cases (17 per 1000). No luteal phase pregnancies occurred in the next 605 sterilizations after institution of same-day pregnancy testing. Eight patients' sterilizations were canceled because of a positive pregnancy test on the morning of surgery. If these patients had not been eliminated, the incidence of luteal phase pregnancies in this second group would have been 13 per 1000 sterilization procedures. CONCLUSION: Same-day pregnancy testing with an ELISA-type pregnancy test is a rapid, inexpensive, and effective means of reducing the incidence of luteal phase pregnancy.